Facilitating sustainable uptake of injectable artesunate

Globally around 438,000 people die each year of severe malaria, around 70% of whom are under the age of 5.1 In 2011, the WHO recommended injectable artesunate (Inj AS) as first-line treatment for severe malaria, as it saves more lives than quinine.2,3 In anticipation of this policy change and to help improve its access, MMV worked with Guilin Pharmaceutical to enable them to obtain WHO prequalification in 2010 for their Inj AS product – Artesun®.

MMV then quickly began work to increase access to Inj AS in Nigeria and the Democratic Republic of Congo – two countries with the highest severe malaria burden in the world. Based on this experience, MMV established a severe malaria consortium with the Clinton Health Access Initiative (CHAI) and the Malaria Consortium (MC) to implement the MMV-led Improving Severe Malaria Outcomes (ISMO) project. In 2013, the project was awarded a UNITAID grant to continue scale-up in Nigeria and five other high-burden African countries (Cameroon, Ethiopia, Kenya, Malawi and Uganda).

Alexis Kamdjou works with teams in the six countries providing technical and analytical support to implement the UNITAID-funded ISMO project. As the project nears the end of its 3-year grant, Alexis talks about his experiences and what has been learnt.

1. As the ISMO project comes to a close in mid-2016, what has been achieved?

As of December 2015, across the six ISMO countries, the proportion of injectable artesunate treatments procured in the public sector compared to quinine was 99.5% in 2015, (compared to 16% in 2013), and the average proportion of patients treated with injectable artesunate versus quinine was 85.5%. These figures alone confirm that during the ISMO project, a major shift to better treatment for severe malaria took place. There were several key steps along the way.

First, thanks to CHAI and MC, we were able to ensure treatment policies were updated in all of the countries. Second, we have trained more than 18,000 health-care workers in more than 1,650 health-care facilities – approximately 50% more than the original objective. Through the training we were able to expand provision of severe malaria care beyond large hospitals. Third, despite the initial limitations of incountry medical quantification systems, we were able to successfully quantify the correct amount of drugs based on need, so that there were almost no stock-outs at the central medical stores.

And finally, we have sought to diversify sources of quality Inj AS, identifying additional manufacturers interested in pursuing WHO prequalification, as a means of ensuring competitiveness and bolstering supply security in the market.

2. What have you learnt?

There has been a wealth of learning that could be applied to other projects:

When implementing a new health project, you need to consider administrative lead times in ministries of health – on average it took 4 months for countries to review and sign memorandums of understanding.

Even if you are helping bring critically-needed life-saving medicines into a country, you may have to pay customs duties or seek appropriate waivers.

When it comes to quantifying a newly launched product, epidemiological data can serve as a basis for first estimates, but it’s more accurate to monitor distribution at the health-care facility level following the first deliveries.

Before you determine your monitoring and evaluation indicators, you need to ensure that appropriate national systems for data collection exist. Creating short-term parallelsystems to collect data just for donor-funded projects is not optimal.

Training is key and most effective when the drugs are already available. When people are well trained they are comfortable using the drugs.

3. What was it like to work on the ISMO project?

It has been a fantastic learning and collaborative experience working with our implementing partners, CHAI and MC; our procurement agent, Missionpharma; and the drug manufacturer, Guilin. It’s also been very satisfying to develop close working relationships with both the Global Fund and the US President’s Malaria Initiative to harmonize our procurement activities.

My overall feeling is extremely positive – health workers who have used Inj AS have consistently responded very positively about their experiences using the medicine. In addition, we have already received feedback from UNITAID, the major funder for this project, that ISMO has achieved its catalytic impact, in line with its original objectives. I think when the end users and the donor are satisfied, the project team can be happy!